Breaking Down the Orbital Fracture

Orbital Fractures are a devastating injury in combat sports such as MMA. Recently, UFC and MMA veteran Joe Riggs suffered an orbital fracture leading to a delay in the much anticipated Bellator FightMaster Finale. Here, a medical guest commentator for FightMedicine.net discusses the oribital fracture.

Orbital Fractures

Orbital fractures are common in mixed martial arts competition. There are many athletes who have documented orbital fractures resulting from mma fights, some requiring surgery and some not. These types of injuries have a lot of variation in terms of location, severity and management. Even though not all of these injuries require surgery it is important that all orbital fractures have a thorough work up by a surgeon experienced in managing these injuries.

Anatomy

The primary function of the orbit is to contain and protect the globe. In addition to housing the globe many blood vessels, nerves and muscles are located within the orbit. The seven bones that make up the orbit are the maxilla, zygoma, sphenoid, lacrimal, ethmoid, palatine and frontal. The outer aspect called the orbital rim consists of strong cortical bone and is designed to protect the contents within the orbit. The four walls known as the orbital floor, orbital roof and the lateral and medial walls are much weaker than the orbital rim and are usually less than 1 mm thick. Due to the thinness of the inferior and medial walls these are the most likely to fracture. This is a protective mechanism to increase the orbital volume after trauma to prevent a significant increase in pressure inside the orbit that would damage the eye itself.

Fracture Types

Only 4-16% of orbital fractures are isolated orbital floor or wall fractures, with orbital floor and medial wall fractures making up the majority. Zygoma, or cheekbone, fractures are the most common type of fracture to also have an orbital floor component. Other types include the nasal and frontal bones.

Evaluation

A complete eye examination should be performed to evaluate the muscles and nerves of the orbit and eye as well as the eye itself. Signs and symptoms of orbital fractures include pain, bruising and swelling, double vision, lacerations, and numbness of the skin, upper lip, gums and teeth. Inability or pain with looking in certain directions, especially up are worrisome for entrapment of the muscles that move the eye within the fracture site.

Many different modalities have been used to evaluate orbital fractures such as conventional x-rays, MRI and ultrasound. However, the current standard imaging for orbital fractures is a CT scan without contrast. The CT scan allows the surgeon to determine the size of the defect, the location of the fracture, the degree of displacement of the segments as well as see any muscles or other soft tissues of the orbit that may be trapped within the fracture site or displaced into the sinus.

Treatment

Not all orbital fractures require surgical intervention to allow healing and normal function. Regardless of whether or not an orbital fracture requires repair there are certain precautions that all patients with these types of injuries should take. Patient’s are instructed not to blow their nose and if they must sneeze to do so in a passive manner. The reason for this is that most orbital fractures have a direct communication with one or more of the sinuses. These are most often the maxillary and ethmoid sinuses for orbital floor fractures and medial wall fractures, respectively. Because of these communications with the sinuses any action that increases pressure in the nose will be relieved via the path of least resistance, which is through the fracture site. This can result in large volumes of air escaping into the orbit. This can result in severe pain, an increased chance of infection and even temporary blindness.

Orbital fractures are considered open fractures because they have a communication with the external environment via the sinuses. Many practitioners will place patients on antibiotics for these fractures regardless of whether or not they are getting surgery because of the contamination from the bacterial flora within the sinuses.

For those patients who don’t have surgery their should be a period of approximately six months where they do not partake in any activities that risk a repeated trauma to the area that could result in worsening of the fracture or further displacement of the segments prior to healing.

So who gets surgery and who doesn’t? The reasons for surgery can be broken down into functional and cosmetic. Regarding function double vision (diplopia), decreased visual acuity and restriction of eye movement due to entrapment are indications for repair.

The main cosmetic deformity resulting from these fractures is enopthalmos, which is when one of the eyes is located in a more posterior position within the orbit than the non-injured side. The cause of this is an increase in orbital volume. It is generally accepted that an orbital floor fracture that is greater than 50% of the floor should have reconstruction to prevent enopthalmos. Patients with greater than 2mm of enopthalmos in the first 2 weeks should have a repair of their fracture.

Surgery

The duration of the surgery is usually about an hour. The surgical incision is placed underneath the eyelid within the conjunctiva (transconjunctival) or in the skin inferior to the eyelid (subciliary). After the incision is made the dissection proceeds to the fractured orbital wall/floor. Any tissue such as fat, connective tissue or muscle is removed from the fracture site and brought back into their correct position. Next an attempt is made to elevate or reduce the fractured segment or segments back into their correct position. This is often not possible, especially in adults, as many times there are multiple small fragmented (comminuted) pieces that are not restorable. Unless there is a single piece of bone that can be brought back into it’s correct position with great stability, an orbital reconstruction must be performed using a bone graft taken from the patient or a synthetic implant. The size of the defect is evaluated and a material is chosen for reconstruction. Materials that have been used to reconstruct defects of the orbit are nylon, gelatin film, bone grafts taken from the patient’s cranium or hip and porous polyethylene. However, the most common material used is a titanium plate with or without the addition of one of the other materials mentioned. After the material is chosen and measured to span the defect it is secured usually to the orbital rim using titanium screws. Prior to closing the incision site the eye is moved in all directions to make sure there are no restrictions of any of these movements. Finally the wound is irrigated and closed in layers.

Recovery

Most patients are able to return home the same day or one day following surgery. Pain associated with the surgery is usually relatively mild and limited to bruising and swelling around the surgical site. This usually subsides within the first week. Most patients are able to return to work in a bout a week after surgery, unless work involves getting punched, elbowed and kicked in the face. Patients should refrain from engaging in any activity where facial trauma is a risk for approximately six months after surgery when the fractures are healed. Long term follow up with the treating doctor is important prior to engaging in combat to ensure healing is complete and there is a return to normal function.